Outcomes of Surgical Treatment and Radiation Therapy in En Plaque Sphenoid Wing

Jiroje Jiranukool MD*, Prasert Iampreechakul MD**, Mantana Dhanachai MD***, Wuttipong Tirakotai MD, MSc, DrMed**

* Department of Surgery, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand ** Department of Neurosurgery, Prasat Neurological Institute, Bangkok, Thailand *** Radiotherapy Unit, Department of Radiology, Ramathibodi Hospital, Bangkok, Thailand

Objective: En plaque sphenoid wing meningioma is a rare tumor. Complete surgical resection is difficult. Role of adjuvant radiation therapy in treatment of is still controversial. This present study aimed to examine the clinical outcomes and to evaluate the role of adjuvant radiation for the residual tumors. Material and Method: A retrospective study was performed in 26 patients with en plaque sphenoid wing meningioma, who underwent operation at Prasat Neurological Institution between January 2008 and December 2012. Presenting symptoms, location of tumor, surgical approach, postoperative outcomes, and adjuvant radiation were reviewed and analyzed. Results: Among the 26 patients, their ages ranged from 31 to 57 years. All tumors were removed by transcranial approach. Eleven of the patients underwent adjuvant radiation therapy and post-radiation imaging revealed tumors being stable in size. Nine patients that had regrowth tumors were not radiated. Mean followed-up time was 51.77 months (range 18-96 months). Conclusion: Proptosis, visual acuity and cosmetic problems can be improved by surgery. Postoperative adjuvant radiation therapy may be an option for residual en plaque sphenoid wing meningioma.

Keywords: En plaque sphenoid wing meningioma, Proptosis, Visual acuity, Pterional approach, Endoscopic endonasal approach, Orbital decompression, Radiation

J Med Assoc Thai 2016; 99 (Suppl. 3): S54-S61 Full text. e-Journal: http://www.jmatonline.com

En plaque meningiomas are rare and constitute Tumor growth can extend anteriorly into the orbital approximately 4% of all meningiomas(1,2). In Prasat apex, posteriorly into the , medially Neurological Institution, en plaque sphenoid wing into sphenoid and ethmoidal sinus, and inferiorly meningiomas are approximately 3.7% of all intracranial into infratemporalfossa(7). Proptosis, the early and meningiomas. The most common location of most common symptom, can be lead to functional meningiomas en plaque type is sphenoid wing(3). The problems and cosmetic deformity(8). The most common characteristics of en plaque meningioma area thin, cranial nerve deficit is optic neuropathy(9). widespread carpet or sheet-like lesion that infiltrates Nowadays, the standard treatment for en the dura and sometimes invades the bone with the plaque sphenoid wing meningioma is surgery, since intraosseous tumor growth leading to significant the high-quality imaging and modern surgical hyperostosis(3,4). This type of meningioma is usually techniques have been developed(1). However, gross diagnosed based on clinical presentation and brain total tumor removal is difficult because of the location images, rather than pathological reports(6). and extension of the tumor(3,10). The goal of surgery is The hyperostosis bone associated with en to remove the entire tumor or as much as possible, plaque sphenoid wing meningioma is mainly located in including hyperostosis bone, thickening dura and the lateral and superior orbital walls, superior orbital intradural parts(1,11). Additionally, the adjuvant radiation fissure, optic canal and anterior clinoid process(5). therapy is still controversial for residual meningioma, especially benign type (WHO grade I)(13-15). The objectives of this present study were to Correspondence to: examinethe results of surgical treatment by comparing Tirakotai W, Department of Neurosurgery, Prasat Neurological preoperative and postoperative symptoms, and to Institute, Rajavithi Road, Rajathewi, Bangkok 10400, Thailand. Phone: +66-2-3069899, Fax: +66-2-3547084 determine the role of the adjuvant radiation therapy for E-mail: [email protected] postsurgical residual tumor.

S54 J Med Assoc Thai Vol. 99 Suppl. 3 2016 Material and Method orsphenoid and ethmoid sinus. Type II tumor involved This present study was a descriptive intraconal, medial orbital wall, cavernous sinus, study.Twenty-six patients,who were diagnosed with infratemporal fossa orsphenoid and ethmoid sinus en plaque sphenoid wing meningioma and underwent (Fig. 2). operation at Prasat Neurological Institution between The main surgical approach was fronto- January 2008 and December 2012, were retrospectively temporosphenoidal (Pterional) approach. Every reviewed. The study was approved by the institutional surgeon tried to obtain the maximal removal of tumor, review board of Prasat Neurological Institute (PNI). and achieve the decompression of orbit and optic The inclusion criteria included intraosseous nerve. Four patients underwent endoscopic endonasal meningiomas at the base of the anterior and middle approach with assisted-navigation for tumor that cranial fossa, involving the sphenoid wing and the orbit located medial orbital wall, sphenoid and ethmoid with carpet-like, soft tissue component with or without sinus, or compressed optic nerve medially. The extent invading the dura and intradural component. Exclusion of resection was evaluated according to the Simpson’s criteria consisted of clinoidal meningiomas, optic nerve grading scale(17). Orbital wall reconstruction was sheath meningiomas, cavernous sinus meningiomas performed in only one case. All tissues, including tumor with intraorbital extension and non-hyperostosis or involved temporal muscle, bone, dura and intradural en mass sphenoid wing meningioma. The data were tumor parts were sent for histopathology and classified collected from medical records, CT and/or MRI images, along with WHO 2007 classification criteria. Patients operative notes and pathological reports. Demographic were followed-up using both clinical symptoms and data, duration of symptoms, location of tumors, images. After surgical resection, the patients were histology, treatment modalities, postoperative clinical sent for postoperative images either CT or MRI for outcomes and imaging were analyzed and summarized. evaluating the residual tumors. Eleven from twenty- Following data were collected for preoperative and five patients that had residual tumors were referred to postoperative comparison. The visual acuity (VA) was the radiooncology center for adjuvant radiotherapy. assessed by Snellen’s chart and classified into The radiation techniques, doses, duration and fivegroups(1): 1) Normal vision; 2) Good vision (>0.5); complications were recorded from the charts. 3) Fair vision (<0.5 to >0.1); 4) No useful vision (<0.1 to 0, Hand movement, finger count or light perception); Statistical analysis and 5) Blindness. Preoperative VA was compared with Descriptive statistics (mean, median, and postoperative VA. Proptosis was evaluated using standard deviation) wereused for demographic data; index (EI). The EI was measured from Chi-square tests were calculated for comparisons image either CT or MRI scan. The distance in millimeters between preoperative and postoperative vision, and from the most anterior aspect of the globe on a section, the measured size of tumor between stable and regrowth including the lens to a line between the bilateral anterior groups. The non-parametric Mann-Whitney U-test was tips of the frontal process of the zygomas, was measured applied to independent samples (age and duration). both affected and normal sides. The ratio of these measures were defined as the EI(8) (Fig. 1). Results For the cosmetic results, we used the criteria Twenty-six patients had median age of 44 that proposed by Carrizo and Basso(16): Level 1: very years (range 31-57 years). Twenty-five were females good with excellent clinical, surgical, and cosmetic and one was male. Multiple meningiomas were found results and without neurological sequelae; Level 2: in 12 patients. Median period of symptoms were 5.5 good, with acceptable clinical, surgical, and cosmetics months (range 1-24 month(s)). All patients presented results; Level 3: moderate, with mild to moderate with proptosis and median of pre-operative neurological sequelae (Incomplete reduction of exophthalmos index was 1.37 (range 1.1-2.43). Nineteen exophthalmos, partial opthalmoplegia); and Level 4: patients had decreased visual acuity and were poor, with severe sequelae and serious complications. classified into four groups: good vision (n = 4, 15.4%), The assessment of EI and tumor locations from images fair vision (n = 2, 7.7%), no useful vision (n = 12, was performed by one radiologist. Tumor locations 46.2%) and blindness (n = 1, 3.8%) (Table 1). Seventeen were classified into two types: Type I tumor was located patients had visual field defects and mostly were at bone, dura and intradural, but not involved intraconal, generalized visual field defect or central visual field medial orbital wall, cavernous sinus, infratemporal fossa defect. Ten patients experienced and seven

J Med Assoc Thai Vol. 99 Suppl. 3 2016 S55 patients had orbital pain. was found in two fronto-temporosphenoidal (Pterional) approach. patients. Cranial nerve III, IV, V, and VI deficit were Four patients underwent second stage endoscopic presented in 1, 1, 3 and 2 patients, respectively endonasal approach with navigation-assisted, because (Table 2). invasion of tumor at sphenoid, ethmoid sinus and medial The locations of all en plaque sphenoid wing orbital wall parts and patients still had symptoms meningioma were found at sphenoid bone, lateral orbital both decreased visual acuity and nasal obstruction. wall, anterior clinoid process and intradural tumor Twenty-five patients were classified as Simpson parts. Tumors were at superior orbital fissures in 24 grade IV along with the extension of resection. patients. Twenty-one and five patients had extraconal Only one patient had Simpson grade II. The intradural and intraconal lesions, respectively. Eighteen patients temporobasal and frontotemporal tumor parts could be had optic canal invasion. Cavernous sinus lesions were totally removed in 19 patients (80.77%). The optic canal detected in 18 patients. Ten patients had infratemporal and extraconal lesions were drilled and totally removed fossa invasion. Sphenoid and ethmoid sinus lesions in 12 and 14, respectively (50% and 66.67%). The lateral were found in 11 and six patients, respectively. Tumors wall andorbital roof were totally removed in 3 (11.05%) were classified as type I (n = 7) and type II (n = 19) and 4 (21.05%), respectively. Bony resection, especially (Table 3). sphenoid bone was totally removed inone patient All 26 patients underwent surgery via the (3.80%). Tumor at cavernous sinus, infratemporal fossa,

Table 1. Visual acuity outcomes

Visual acuity Number of patients

Preoperative Postoperative

Normal Good Fair No useful Blind

Normal 7 (26.9%) 7 (26.9%) 0 0 0 0 Good vision 4 (15.4%) 2 (7.7%) 2 (7.7%) 0 0 0 Fair vision 2 (7.7%) 1 (3.8%) 1 (3.8%) 0 0 0 No useful vision 12 (46.2%) 2 (7.7%) 3 (11.5%) 2 (7.7%) 4 (15.4%) 1 (3.8%) Blind 1 (3.8%) 0 0 0 0 1 (3.8%)

Table 2. Preoperative and postoperative presenting symptoms

Symptoms Number of patients

Preoperative Postoperative symptoms symptoms Improved Unchanged Worsened

Proptosis 26 (100%) 24 (92.3%) - 2 (7.7%) Decrease visual acuity 19 (73.1%) 11 (57.9%) 7 (36.8%) 1 (5.3%) Visual field defect 17 (65.4%) 5 (29.4%) 9 (52.9%) 3 (17.7%) Headache 10 (38.5%) 10 (100.0%) - - Orbital pain 7 (26.9%) 7 (100.0%) - - Diplopia 2 (7.7%) - 2 (100%) - Cranial III deficit 1 (3.8%) - 1 (100%) - Cranial IV deficit 1 (3.8%) - 1 (100%) - Cranial V deficit 3 (11.5%) - 3 (100%) - Cranial VI deficit 2 (7.7%) - 2 (100%) -

S56 J Med Assoc Thai Vol. 99 Suppl. 3 2016 Table 3. Locations of 26 tumors from preoperative and postoperative images,including percent of complete resection

Locations Number of patients Number of patients with % complete resection with preoperative postoperative imaging imaging findings findings

Sphenoid bone 26 (100%) 25 (96.2%) 3.8% Temporal bone 23 (88.5%) 18 (69.2%) 21.7% Frontal bone 8 (30.8%) 3 (11.5%) 62.5% Lateral orbital wall 26 (100%) 23 (88.5%) 11.5% Orbital roof 19 (73.1%) 15 (57.7%) 21.1% Medial orbital wall 4 (15.4%) 3 (11.5%) 25.0% Superior orbital fissure 24 (92.3%) 12 (46.2%) 50% Inferior orbital fissure 11 (42.3%) 11 (42.3%) 0 Anterior clinoid process 26 (100%) 13 (50.0%) 50.0% Optic canal 18 (69.2%) 6 (23.1%) 66.7% Extraconal invasion 21 (80.8%) 7 (26.9%) 66.7% Intraconal invasion 5 (19.2%) 3 (11.5%) 40.0% Cavernous sinus 18 (69.2%) 18 (69.2%) 0 Infratemporal fossa 10 (38.5%) 10 (38.5%) 0 Foramen rotundum 10 (38.5%) 10 (38.5%) 0 Foramen ovale 5 (19.2%) 5 (19.2%) 0 Temporal muscle 10 (38.5%) 7 (26.9%) 30.0% Sphenoid sinus 11 (42.3%) 10 (38.5%) 9.1% Ethmoid sinus 6 (23.1%) 3 (11.5%) 50.0% Intradural temporobasal region 24 (100%) 5 (19.2%) 79.2% Intradural fronto & temporal region 2 (7.7%) 0 (0%) 100%

inferior orbital fissure, foramen rotundum and foramen before surgery and was blinded after surgery (Table 1). ovale parts were not removed. Medial orbital part was Visual field defect improved in five patients (19.20%), drilled and totally removed in onepatient (25%). unchanged in nine patients (34.60%) and worsened in Sphenoid sinus and ethmoid sinus parts were totally three patients (11.50%). All patients, who had headache removed in one (9.09%) and three patients (50%), and orbital pain before surgery, improved symptoms respectively. Orbital wall reconstruction was performed after surgery. No cranial nerve deficits improved after in only one case (Table 3). surgery (Table 2). The histological assessment revealed In aspect of cosmetic results, 17 patients transitional (n = 15, 57.70%), microcystic (n = 7, 26.90%), (65.40%) were level 2, six patients (23.10%) were level 3 angiomatous (n = 2, 7.70%), meningothelial (n = 1, and three patients (11.50%) were level 1. Complications 3.80%) and fibrous (n = 1, 3.80%). All subtypes were after surgical resection were cranial nerve deficits in classified as WHO grade I. The histological examination four patients (15.40%) and these were transient provided proof of muscle and bone infiltration. abducens nerve deficit in two patients, and one each The postoperative proptosis symptom was transient oculomotor nerve deficit and frontalis improved in 24 patients (92.30%). The median of paralysis. CSF leakage was found in two patients postoperative exophthalmos index was 1.34 (range (7.70%) who underwent transcranial approach. Both 1.07-1.60). The visual acuity was improved in 11 patients patients were treated by placement of spinal drain. (42.30%), unchanged in seven patients (26.90%) and Postoperative seizure was found in twopatients (7.7%). worsened in one patient (3.80%). The Good and Fair One patient revealed a postoperative epidural empyema vision groups had visual improvement in four patients at surgical site. The patient was managed by and unchanged in two patients. The group of No useful debridement and removing bone flap, as well as vision had VA improvement in seven patients and no intravenous antibiotics. improvement in five patients. The only one patient, Eleven in twenty-five patients that had who worsened in VA, presented with light perception residual tumor after resection were referred to the radio-

J Med Assoc Thai Vol. 99 Suppl. 3 2016 S57 oncological center for adjuvant radiation therapy. stable tumor, including multiple meningioma, tumor type Radiation therapy selected for the individual was IMRT and type of surgery (Table 4). (Intensity Modulated Radiation Therapy) in five patients and SRT (Stereotactic Radiation Therapy) in Discussion six patients. All radiation fields covered the entire tumor From a literature review, the proptosis was both resection parts and residual parts. The dose per the early and most common (49-100%) presenting fraction and total doses varied and depended on the symptom in en plaque sphenoid meningiomas(1-3,5,6-10). recommended dose and tolerated lower daily dose of In this present study, we found that the proptosis is an radiation to the surrounding tissue. early presenting symptom in all cases (100%). The mean follow-up period was 51.77 months Sammartino et al(18) distinguished the differences (range 18-96 months); we found regrowth tumors in between the proptosis caused by direct invasion of nine patients and stable in size of tumors in 16 patients. the orbital cavity and the proptosis caused by One patient was not found tyo have a recurrent tumor. cavernous sinus and superior orbital fissure invasion. In stable tumor groups, 11 in 16 patients underwent Scarone et al(8) explained the pathophysiological adjuvant radiation therapy. The median follow-up mechanisms leading to proptosis which were not period in adjuvant radiation group was 21.5 months only based on slow and progressive osseous invasion (range 6-54 months) and stable tumor size was found in by the tumor, but dural infiltration at the level of all without serious side effects. Nine patients had superior orbital fissure can cause reduction of venous regrowth tumors. The presenting symptoms of drainage from the orbit that induced producing recurrence were proptosis in all and seven patients proptosis, and can happen early in the disease process. presented with . The mean duration In this present study, we found the duration of proptosis of the regrowth group was 14 months (range 5-33 symptoms occurred between 1-24 months. The early months). Nine patients, who had regrowth tumor, were presenting symptom may be explained from the tumors underwent surgery via transcranial approach and three that invaded superior orbital fissure or cavernous sinus. patients were given radiation after surgery. Factor that The surgery for orbital decompression can reduce the affected the outcomes for stable tumor groups was proptosis (92.3%) by comparing exophthalmos index radiation after surgery (p = 0.002). Neither age nor between pre-operative index of 1.37 and postoperative duration of pre-operative symptoms correlated with index of 1.34. The difference between pre-operative and

Table 4. Univariate analysis of stable tumor groups

Follow-up tumors p-value Odd ratio 95% CI

Stable Regrowth (n = 16) (n = 9)

Age (years) Median 44 Median 43 0.465 0.935 0.8-1.093 Duration (months) Median 4 Median 9 0.624 0.996 0.874-1.136 Multiple meningioma 0.628 1.786 0.349-9.127 Yes 7 5 No 9 4 Tumor type 0.611 1.625 0.237-9.658 I 43 II 13 6 Surgery 1.000 1.714 0.152-19.359 1148 2 31 Radiation 0.002 0 0 Yes 11 0 No 5 9

Total patients = 25, 1 patient had no residual tumor postoperatively.

S58 J Med Assoc Thai Vol. 99 Suppl. 3 2016 postoperative exophthalmos index seems to be slight, with assisted-navigation to remove the tumor, involving however, when interviewing with the patients, there parts of medial orbital wall, sphenoid sinus and were only six patients who were unsatisfied with the ethmoid sinus, may be an alternative treatment. cosmetic outcomes from incomplete reduction. The Although these tumor parts could not be totally adequate drilling and removal of bony orbital wall were removed, surgeon could decompress the affected optic important in reducing proptosis. nerve and opened the obstructed nasal sinus. Four Oya et al(5) reported that 37% to 75% of cases patients felt of clear nasal airway, reduced orbital pain experienced the improvement of visual deficit and had no postoperative complications, but the postoperative. In this present study, improvement of improvement in visual acuity was unclear due to the the visual acuity was found in 42.30% of the cases. worsening initial visual acuity (no useful visual The patients with good and fair vision had a better function). prognosis than the patients with no useful vision. We In this present study, most tumors, involving concluded that the severity of pre-operative visual the sphenoid bone, lateral orbital wall, orbital roof, acuity impairment was an important prognostic factor temporal bone and anterior clinoid process, would be of postoperative visual acuity improvement. Optic attempted to be removed. In addition to the anatomical nerve decompression is one goal of the surgical knowledge, the use of navigation system may have a resection because it can improve the visual acuity or role in enhancing the volume surgical resection and prevent further impairment. Surgeons should try to providing the orientation during the bony removal. remove lesions that compressed or located around the For the intradural tumor at temporobasal and fronto- optic nerve. temporal regions, all intradural tumors could be resected Schick et al(1) explained that en plaque about 80.77%, compared to other regions. This could sphenoid wing meningioma was a sub group of be explained by the location in which the regions may meningiomas. Their characteristics were a carpet or be not so large and not too deep from dura. Maroon et sheet-like appearance invading the dura and the bone. al(9) suggested that it was not necessary to reconstruct The infiltration of bone by meningioma cells stimulates the orbital roof or to inlay any bone or other materials osteoblastic activity, resulting in hyperostosis. The in the capacious space after resection of tumor- hyperostotic bone is pathological with meningiomatous involved bone which we agreed with. cells invading the Haversian canals. Therefore, Pendl et al(20) reported the results about hyperostosis bone should be regarded as part of gamma knife therapy in skull base meningioma. In this the tumor. These tumors mostly invaded the adjacent present study, 51% of cases were found reduction in structures, for example optic canal, superior orbital tumor size, 47% of cases found constant in tumor size, fissure, extraconal, intraconal, cavernous sinus, and 2% of cases found increase in tumor size. Maroon infratemporal fossa and sphenoid, ethmoid sinus. In et al(9) recommended the postoperative adjuvant this present study, tumor involving the cavernous radiation in residual en plaque sphenoid wing sinus, infratemporal fossa, inferior orbital fissure, meningioma or invaded to cavernous sinus. In this foramen rotundum and foramen ovale were not removed present study, eleven patients who had residual tumor due to the difficulties in surgical resection. The aims after resection, especially in cavernous sinus and of surgical resection are improvement of visual acuity, infratemporal fossa, were submitted to adjuvant reducing proptosis, good cosmetic outcome and radiation. All patients, who received the adjuvant regrowth or recurrence risk prevention. radiation, were not found to have the regrowth tumors. Previous studies identified various surgical Thus, we recommended the adjuvant radiation as an approaches such as combined transcranialsubfrontal- option in cases of residual en plaque sphenoid wing transmalar approach(15), fronto-temporo-sphenoidal meningioma. However, the duration of follow-up (pterional) approach and fronto-temporal craniotomy after radiation was about 25.57 months, thus the longer extending into the orbito-zygomaticomalar bone duration of follow-up issuggested. ridge(18). In this present study, all of twenty-six cases Limitations of this study included data underwent surgery with fronto-temporosphenoidal interpretation based on the patients’ records. Moreover, (pterional) approach. For tumors that were located in the treatment decision such as the extent of tumor medial orbital wall, sphenoid sinus and ethmoid sinus, resection was depended on each individual surgeon. they were difficult to be resected via pterional approach. There were five neurosurgeons performed operation in We proposed that the endoscopic endonasal approach this present study. The measurement in exopthalmos

J Med Assoc Thai Vol. 99 Suppl. 3 2016 S59 index was done by one radiologist. 4. Cushing H, Eisenhardt L. The meningiomas: Their classification, regional behavior, life history, and Conclusion surgical end results. Springfield: Charles C Thomas; En plaque sphenoid wing meningioma is a rare 1938. type of benign tumor. Proptosis, visual acuity and 5. Oya S, Sade B, Lee JH. Sphenoorbital meningioma: cosmetic problems can be improved by surgery. The surgical technique and outcome. J Neurosurg 2011; severity of pre-operative visual acuity impairment is an 114: 1241-9. important factor in prognosis of visual outcomes. The 6. Simas NM, Farias JP. Sphenoid Wing en plaque goal of treatment is total removal of tumor because it meningiomas: Surgical results and recurrence rates. can improve the presenting symptoms and prevent the Surg Neurol Int 2013; 4: 86. regrowth. However, the complete resection of a tumor 7. Shrivastava RK, Sen C, Costantino PD, Della RR. is difficult due to location and extension of the tumor. Sphenoorbital meningiomas: surgical limitations Endoscopic endonasal approach can be an alternative and lessons learned in their long-term management. approach for tumor in medial orbital wall, sphenoid J Neurosurg 2005; 103: 491-7. and ethmoid sinus. Postoperative adjuvant radiation 8. Scarone P, Leclerq D, Heran F, Robert G. Long-term therapy may be an optional treatment for residual en results with exophthalmos in a surgical series of plaque sphenoid wing meningioma. 30 sphenoorbital meningiomas. Clinical article. J Neurosurg 2009; 111: 1069-77. What is already known on this topic? 9. Maroon JC, Kennerdell JS, Vidovich DV, Abla A, Surgical resection can improve the visual Sternau L. Recurrent spheno-orbital meningioma. acuity and reduce the degree of proptosis. Radical J Neurosurg 1994; 80: 202-8. resection decreases the recurrence of tumor. However, 10. Ringel F, Cedzich C, Schramm J. Microsurgical aggressive resection of tumor that invades the technique and results of a series of 63 spheno- cavernous sinus and superior orbital fissure can orbital meningiomas. Neurosurgery 2007; 60: 214- increase the morbidity rate.The adjuvant radiation 21. therapy is still controversial for residual meningioma, 11. Brotchi J, Levivier M, Raftopoulos C, Noterman J. especially benign type (WHO grade I). Invading meningiomas of sphenoid wing. What must we know before surgery? Acta Neurochir What this study adds? Suppl (Wien) 1991; 53: 98-100. Radiation therapy for en plaque sphenoid wing 12. Jho HD, Carrau RL. Endoscopic endonasal meningioma should be considered if residual tumor transsphenoidal surgery: experience with 50 remains postoperatively. The endoscopic endonasal patients. J Neurosurg 1997; 87: 44-51. approach with navigation-assisted is an option for 13. Engelhard HH. Current status of radiation therapy removing the tumor involving medial orbital wall, and in the treatment of intracranial sphenoid sinus and ethmoid sinus parts. However, it is meningiomas. Neurosurg Focus 1997; 2: e6. not the main surgical approach. 14. Goldsmith BJ, Wara WM, Wilson CB, Larson DA. Postoperative irradiation for subtotally resected Potential conflicts of interest meningiomas. A retrospective analysis of 140 None. patients treated from 1967 to 1990. J Neurosurg 1994; 80: 195-201. References 15. Lunsford LD. Contemporary management of 1. Schick U, Bleyen J, Bani A, Hassler W. meningiomas: radiation therapy as an adjuvant and Management of meningiomas en plaque of the radiosurgery as an alternative to surgical removal? sphenoid wing. J Neurosurg 2006; 104: 208-14. J Neurosurg 1994; 80: 187-90. 2. Mirone G, Chibbaro S, Schiabello L, Tola S, George 16. Carrizo A, Basso A. Current surgical treatment for B. En plaque sphenoid wing meningiomas: sphenoorbital meningiomas. Surg Neurol 1998; 50: recurrence factors and surgical strategy in a series 574-8. of 71 patients. Neurosurgery 2009; 65: 100-8. 17. Simpson D. The recurrence of intracranial 3. Li Y, Shi JT, An YZ, Zhang TM, Fu JD, Zhang JL, et meningiomas after surgical treatment. J Neurol al. Sphenoid wing meningioma en plaque: report Neurosurg Psychiatry 1957; 20: 22-39. of 37 cases. Chin Med J (Engl) 2009; 122: 2423-7. 18. Sammartino A, Cerbella R, Cennamo G,

S60 J Med Assoc Thai Vol. 99 Suppl. 3 2016 Corriero G. Exopthalmos induced by intracranial “en plaque” meningiomas. Plast Reconstr Surg meningiomatosis. Orbit 1986; 5: 39-44. 1997; 100: 1113-20. 19. Gaillard S, Pellerin P, Dhellemmes P, Pertuzon B, 20. Pendl G, Eustacchio S, Unger F. Radiosurgery as Lejeune JP, Christiaens JL. Strategy of craniofacial alternative treatment for skull base meningiomas. reconstruction after resection of spheno-orbital J Clin Neurosci 2001; 8 (Suppl 1): 12-4.

. .     

      ⌫ ⌫     .  

 .        . ⌫     . .  . .. ⌫  ..... ..⌦. ..⌫.⌫ ⌫ ..         ⌫⌫  .     .⌦         ⌫  .. . ⌫ . .⌫ ⌦   .    .    ⌫      . ⌫ .         . ⌫  . ⌫ .   . ⌫   . .⌫ ⌫    ⌫ .⌫ . .     ⌫  .     .        ..⌫⌦.⌫.. ...⌫..

J Med Assoc Thai Vol. 99 Suppl. 3 2016 S61